Paternity after adolescent varicocele repair

Positive Effects of a Resveratrol-Based Nutraceutical in Association with Surgical Scleroembolization: A Pilot Retrospective Clinical Trial

Background: Varicocele still today represents a common cause of infertility in young men. The treatment strategy remains a surgical approach such as scleroembolization; however, the complete restoration of spermatic parameters afterward requires an average of six or more months to fully regain optimal seminal parameters. Recently, many studies have demonstrated the beneficial effects of Resveratrol in male fertility, given its potential anti-inflammatory, antiapoptotic, and mitochondrial effects. Therefore, Resveratrol-based nutraceuticals could be promising as an adjuvant to mitigate subfertility in patients with varicocele. Methods: In the present study, we retrospectively analyzed the effects of the administration of a Resveratrol-based nutraceutical after the scleroembolization procedure. The improvement of sperm quality in terms of number, motility, and morphology were considered to be the study's main endpoints. A spreadsheet program was used for data analysis, and a p-value of <0.05 was considered significant. Results: We found a statistically significant improvement in the spermatic parameters (sperm count and total motility) and an increase in normal sperm after only 4 months of treatment. The supplementation with a Resveratrol-based nutraceutical associated with the surgical procedure showed encouraging results if compared to data from a control group and the results reported in the literature linked to scleroembolization practice alone. In fact, there was a clear improvement in the seminal parameters at 4 months. Conclusions: This suggests the positive impact of the Resveratrol-based nutraceutical in synergizing with scleroembolization in reducing the time needed to fully recover sperm function.

Patient Satisfaction and Long-Term Clinical Outcomes in Adolescent Sub-inguinal Microscopic Varicocelectomy

INTRODUCTION AND OBJECTIVE

The long-term outcomes of varicocelectomy in adolescents is debated. The aim of this study was to evaluate symptom improvement, hypogonadism, and paternity in those who underwent adolescent sub-inguinal microscopic varicocelectomy.

MATERIAL AND METHODS

A retrospective chart review was done of adolescents (median=19, interquartile range (IQR)=16-19.75 years) who underwent microscopic varicocelectomy between 2011 and 2021. Demographics, surgical indications, and outcomes were collected, as well as pre- and postoperative hormone levels and semen parameters. A questionnaire was prospectively collected to evaluate orchialgia, paternity, and symptoms of hypogonadism. Descriptive statistics and t-tests were performed, with significance assessed at p-value < 0.05.

RESULTS

A total of 46 adolescents were included. Age at the time of diagnosis and surgery was 19 (IQR=16-20) and 19 (IQR= 18-21) years, respectively. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), and total testosterone were not affected after surgery. Similarly, semen parameters were preserved after varicocelectomy, with median concentration increasing from 12x106/ml to 16x106/ml but not reaching significance (p=0.272). A total of 26 men completed the questionnaire. The age of responders was 22 (IQR=21-24) years, and the time after having had the varicocelectomy was 36.5 (IQR= 18.25-62.25) months. Orchialgia persisted in five men, and three reported having a recurrence. Two men, who had a preoperative abnormal semen analysis, were actively trying to have children and reported successfully having achieved natural pregnancies. None of the patients reported having hypogonadism, and none were receiving testosterone therapy.

CONCLUSION

Our study suggests that microscopic varicocelectomy in adolescents appears to be a safe and feasible procedure with a low rate of syndrome recurrence and no association with symptoms or biochemical evidence of hypogonadism.

Does Varicocele Treatment in Adolescence Improve Fertility Outcomes in Adulthood?

Many questions on diagnosis of varicocele in adolescent patients have yet to be adequately answered, particularly regarding paternity outcomes after treated in comparison to conservative monitoring. There have been some promising outcomes after surgical treatment, particularly microsurgical varicocelectomy, but the results are mixed and may not be comparable because of differing variables. Future studies with robust methodologies are needed to identify which adolescents require treatment and when treatment should be initiated to avoid any detrimental effects on future fertility.

Varicocelectomy in adolescents - Does it safeguard future fertility? A single centre experience

BACKGROUND

There is paucity of literature comparing varicocelectomy to observant management amongst adolescent boys with hormonal and semen abnormalities resulting from high grade unilateral varicoceles and consequent testicular volume loss. Furthermore, it is not known whether surgical correction in such adolescents improves paternity rates in future compared to their non-operated cohort.

OBJECTIVE

The primary objective was to compare adolescent boys with unilateral high grade varicocele with associated ipsilateral testicular volume loss who were operated versus those who were not, in relation to their fertility markers (hormonal, semen parameters, and testicular volume) over a 5 year follow up period. The secondary objective was to compare the paternity rates in the respective groups over long term.

STUDY DESIGN

This was a single center, retrospective study of a prospectively maintained database conducted from 2010 to 2020, based on a standardized protocol. All adolescent boys >15 years of age (middle and late adolescence), with grade II or III unilateral varicoceles with abnormal fertility markers, who were operated (Group A) and not operated (Group B) were included. The changes in hormonal assay, sonographic assessment, semen analysis at presentation, 1st year and the 5th year follow up amongst both the groups were collated and analysed. Primary paternity rates amongst both the groups was documented by telephonic or email conversations.

RESULTS

Of the 182 boys referred for varicocele management, 110 boys (Group A -70 boys and Group B - 40 boys) satisfied our inclusion criteria and were analysed. Mean age at presentation amongst Group A boys was 16.5 years (15-18 years) and Group B boys was 16 years (15-18 years). Grade III varicoceles were more predominant amongst both the groups. There was a significant improvement in all Group A boys (operated) in the fertility markers from the time at presentation to the 5th year follow up (p < 0.001). In Group B, (boys not operated) there was no significant improvement in the above parameters. The testicular catch up growth was 92% at the 5th year follow-up in Group A and 42% in Group B. At long term follow-up, the paternity rate was 80% and 36% in Group A and B respectively.

DISCUSSION AND CONCLUSION

In adolescent boys in whom hormonal assay, testicular volumes and semen characteristics are negatively affected by high grade unilateral varicoceles, surgical correction could normalize these values, thereby safeguarding their fertility in the long term.

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel

CONTEXT

The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial.

OBJECTIVE

To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion.

EVIDENCE SYNTHESIS

Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates.

CONCLUSIONS

Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown.

PATIENT SUMMARY

In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

Update on the novel management and future paternity situation in adolescents with varicocele

Varicocele is a progressive disease, and the incidence of varicocele and varicocele related testicular hypotrophy increases with puberty. This review updates novel management and future paternity potential in adolescents with varicocele. Main goal of treatment of the adolescent varicoceles is preservation of fertility. Current recommendations for adolescent varicocele repair are testicular hypotrophy (>2 mL or >20%) on the affected side and/or impaired spermatogenesis in the post-pubertal period. The best treatment modality for adolescent varicocele should include elimination of the varicocele with lower complication rates. Microsurgical varicocelectomy techniques have been shown to result in fewer recurrences and postoperative complications than conventional varicocelectomy in adolescents. We conducted a meta-analysis, including 2 studies with the control groups, and reporting paternity situation after varicocele treatment. In this meta-analysis, varicocele repair increases paternity rate 2.42 times with a p value of 0.000. Adolescents with varicocele and their families should be counselled in the light of these findings.

Preoperative duplex ultrasound parameters predicting male fertility after successful varicocelectomy

OBJECTIVES

To assess duplex ultrasound (DUS) parameters, and predicti the outcome of varicocele ligation in male infertility. 

METHODS

This retrospective and follow up study was conducted at Dr. Sulaiman Al Habib Hospital, AlQassim, Saudi Arabia between January 2011 and December 2012. Eighty-two patients were selected, who presented with clinical/subclinical varicocele and male infertility. All these patients had DUS of the scrotum and underwent for low ligation varicocelectomy. These patients were followed for a period of 12-24 months after surgery for the occurrence of paternity. We reviewed pre-operative scrotal DUS of these 82 patients for the testicular size and volume, pampiniform veins caliber and duration of reflux in the dilated veins at rest, and after valsalva maneuver. These DUS parameters were correlated with the postoperative paternity rate.  

RESULTS

Postoperative paternity was achieved in 18 patients (31.6%) with normal-sized testes, and in 3 patients (12%) with small size testes. The positive paternity rate was higher (38.5%) in patients with clinically detected varicocele, compared with only 16.7% of patients with subclinical varicocele (detected by ultrasound only). In addition, postoperative paternity was significantly higher in patients with bilateral varicocele (70.6%), with shunt-type varicocele (71.4%), and patients with a permanent grade of venous reflux (62.5%).  

CONCLUSION

Selection of patients for the successful paternity after varicocele repair depends mainly on DUS parameters, which includes normal size testicles with shunt type of bilateral varicocele and continuous reflux.

Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

BACKGROUND

The American Society for Reproductive Medicine Practice Committee recommends obtaining a semen analysis (SA) in pediatric patients presenting with a varicocele in the absence of significant testicular atrophy. Among infertile adults with a varicocele, surgery is indicated in the presence of abnormal semen analysis regardless of testicular atrophy. Despite these two statements, semen analysis is not widely utilized by pediatric urologists in the USA managing a patient with a varicocele.

OBJECTIVE

We explored the attitudes of patients, parents, and practitioners toward SA to identify potential barriers to the use of SA in the evaluation of the adolescent varicocele.

STUDY DESIGN

We conducted a survey of Society for Pediatric Urology members regarding their management of adolescent varicoceles, with focus on the utilization of SA. The survey consisted of 14 multiple choice questions and two open-ended questions regarding use of SA in practice, barriers to its use, indications for varicocelectomy, and demographics. We also surveyed patients presenting for initial evaluation of a varicocele, as well as their parents, regarding their knowledge about SA and their attitude towards obtaining it. Statistical analysis was performed (p < 0.05 significant).

RESULTS

The practitioner survey response rate was 53% (168). Only 13.1% routinely incorporated SA in their practice, with 48% of all responders having some degree of discomfort asking for a SA. Of practitioners who cited discomfort, 90% never order a SA for patients with varicoceles. From the 46% of physicians who ordered a SA, we noted significant practice variability (see Figure). The patient/parent survey demonstrated that this population was uncomfortable with the notion of obtaining a SA, with most patients/parents citing lack of knowledge about SA as the main barrier. Patient and parent knowledge was found to correlate.

DISCUSSION

This study uniquely addresses an issue that has not been discussed in the adolescent varicocele literature to date. It can increase awareness of the option of incorporating SA data in management of the adolescent who presents with a varicocele.

CONCLUSION

Recognizing and then breaking through the barriers to obtaining a SA, would improve patient care, providing a direct assessment of the impact of a varicocele on fertility potential and thus best determining which patients require surveillance versus surgical intervention. This study suggested that the barriers to SA are surmountable.

My indications for treatment of the adolescent varicocele (and why?)

What to do with the adolescent varicocele? With merging the information obtained from an extensive review of the literature with our own clinical research, I believe that we already have knowledge enough to say that the adolescent with a varicocele often is in the midst of a progressive disease process. Strong evidence already exists that well more than the majority of Tanner 5 boys with a varicocele and 20% asymmetry will already have abnormally low total motile sperm counts (TMCs) and likely abnormally low sperm concentration as well. There are now many studies in addition to common sense to support the value of % asymmetry as a marker of future abnormal sperm parameters. While we know that some boys at lower Tanner stages who present with asymmetry will have catch-up growth during adolescence, we also know that almost all boys with 15% asymmetry or greater in conjunction with a Doppler detected peak retrograde flow (PRF) of 38 cm/s or greater will end up with greater than 20% asymmetry on follow-up. There also are some boys of concern with less asymmetry but instead have small testes bilaterally, perhaps as a result of the left varicocele slowing the growth of the right testicle and/or an associated undetected or overlooked palpable right varicocele that is also negatively affecting the right testicle. Fortunately, we now have another marker available, i.e., total testicular volume (TTV), to assist in decision making for the adolescent falling into this scenario. Once markers are in place in an early Tanner stage boy with a varicocele that indicate that abnormal semen parameters will likely be present when a Tanner 5 stage of development is reached, there is no reason to wait until the child is older so that a semen analysis can be comfortably requested for the documentation. One argument in favor of waiting is that abnormal semen parameters in a Tanner 5 male usually are reversible. However, how do we know that once abnormal parameters are reversed they then will stay normal in a testicle that already has incurred damage. In other words, I feel it is best to operate once the indicators are in place. We do not want to be suddenly surprised when that individual when older has difficulty fathering a child at a time in life when surgery might be too late to resolve what has taken years to develop. Within this manuscript I will try to document my reasons for the aforementioned rationale.

Adolescent Varicoceles and Infertility

Varicoceles are associated with testicular atrophy and abnormal spermatogenesis. Varicocele-related testicular damage is thought to be progressive in nature. Adult varicoceles are common in men with infertility, and varicocele repair in this population has demonstrated improved semen parameters and paternity outcomes. However, without solid objective endpoints (reproducible semen analyses, paternity), the indications for adolescent varicocele repair remain controversial. Given the controversy surrounding adolescent varicocele management, it is not surprising that surveys of pediatric urologists have revealed a lack of consensus on diagnostic approaches, treatment decisions, and operative approaches.

The dilemma of adolescent varicocele

Adolescent varicocele is associated with ipsilateral testicular hypotrophy and the concern for future infertility. A testicular size discrepancy greater than 15-20 % between left and right testicle is an indication for treatment to allow catch-up growth in the hope of preventing a future decline in fertility. Some authors advocate for a period of watchful waiting, as normal testicular growth may occur asymmetrically. We review the current literature to highlight some controversies and challenges in management.

Morphological and surgical overview of adolescent testis affected by varicocele

Varicocele is a common pathology of the testis frequently associated with infertility. For its management, a fine morphological study of the testis, both macroscopically and microscopically, and an accurate choice of surgical procedure are mandatory. The present review focuses its attention on the anatomic substrates of adolescent varicocele and its pathophysiologic modifications. The comprehensive assessment of all the reported alterations should be considered by the clinician before deciding the type of treatment and the timing.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

The hemodynamic approach to evaluating adolescent varicocele

During adolescence, the risk of developing a varicocele increases. Prevalence is less than 1% in boys aged younger than 10 years, but approaches that of the general adult population (about 15%) during puberty. For adolescent males with varicoceles, surgical risk factors have not yet been clearly delineated and clinical severity correlates poorly with prognosis. Fortunately, the widespread use of Doppler ultrasonography is transforming the diagnostic work-up for this demographic. A continuous reflux detected by color Doppler ultrasound (CDUS) is thought to have a negative prognostic value and evidence suggests that a peak retrograde flow above 38 cm per second is a powerful predictor of lack of spontaneous improvement in adolescent patients with ≥ 20% asymmetry between testes. CDUS also enables the detection of varicocele resulting from reflux in the deferential vein adjunctive to a refluxing internal spermatic vein; a causality that accounts for approximately 15% of cases. In addition to a diagnostic role, hemodynamic parameters can be used to predict the risk of persistence or worsening asymmetry. Although further studies are necessary to validate single parameters, it seems that the more severe the reflux, the greater the likelihood that the patient will develop testicular asymmetry.

Varicocelectomy in adolescent boys: long-term experience with the Palomo procedure

PURPOSE

We report our long-term experience with the Palomo technique for varicocele ligation in the pediatric population.

MATERIALS AND METHODS

Between August 1986 and December 2006, 312 patients 7 to 21 years old (median age 14.6) underwent varicocele ligation using the Palomo technique for complete retroperitoneal ligation of the internal spermatic veins and artery. In 234 patients the varicocele was grade III, in 75 it was grade II and in 3 it was grade I. Indications for surgery were relative left testicular volume loss compared to the right testicle in 248 patients, bilateral palpable varicoceles in 8 and pain or parental preference in the remainder. Postoperative followup was 2 weeks to 10.6 years (mean 17.4 months). A total of 233 patients had at least a 6-month followup.

RESULTS

Persistent varicocele was noted in 9 of 233 patients (3.9%). Of the 233 patients 68 (29%) presented with a secondary hydrocele an average of 14 months (range 18 to 1,964 days) following surgery, of whom 12 (17.6%) underwent hydrocele correction. The 12 patients who underwent hydrocelectomy represented 5% of the patients with varicocelectomy. Postoperative testicular atrophy was not documented in any patient and no other surgical complications were noted.

CONCLUSIONS

The Palomo procedure for adolescent varicocele repair is safe and effective with a high success rate and low complication rate. Postoperative hydrocele formation developed in 29% of our patients. However, most secondary hydroceles were small, asymptomatic and did not require surgical correction.

Laparoscopic lymphatic sparing varicocelectomy in adolescents

PURPOSE

Laparoscopic varicocelectomy is similar to an open Palomo repair. Both procedures involve en masse ligation of the internal spermatic cord, and both are associated with a 1% to 3% incidence of recurrence and up to a 30% incidence of hydroceles. We sought to determine the impact of lymphatic preservation on hydrocele formation and the success of varicocelectomy.

MATERIALS AND METHODS

We retrospectively evaluated 191 patients with a mean age of 15.2 years who underwent laparoscopic varicocelectomy and at least 6 months of followup. Patients were divided into 2 groups-those who had undergone a lymphatic sparing procedure and those who had undergone a nonlymphatic sparing technique. The incidence of recurrence/persistence, postoperative hydrocele formation and postoperative hydrocele requiring surgery or aspiration was analyzed.

RESULTS

A total of 174 laparoscopic lymphatic sparing procedures (132 patients, 42 bilateral) and 88 nonlymphatic sparing repairs (59 patients, 29 bilateral) were performed, with a mean followup of 26.1 months. Lymphatic sparing surgery was associated with a decreased incidence of postoperative hydrocele (3.4% vs 11.4%, p = 0.025). There was no significant difference in incidence of persistent or recurrent varicocele requiring reoperation following lymphatic sparing (5 sides, 2.9%) vs nonlymphatic sparing (4 sides, 4.5%) varicocelectomy (p = 0.736).

CONCLUSIONS

Laparoscopic lymphatic sparing varicocelectomy is preferable to an open or laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles, especially those requiring surgical intervention, and still maintains a low incidence of persistence/recurrence. The procedure is especially advantageous for bilateral varicocelectomy.

Single-port laparoscopic surgery: initial experience in children for varicocelectomy

OBJECTIVE

To present our initial experience in children undergoing single-port laparoscopic varicocelectomy (SPLV) using a new approach in which the entire procedure is performed through a multichannel single laparoscopic port inserted in the umbilicus rather than the traditional LV performed through three abdominal ports.

PATIENTS AND METHODS

We reviewed our experience with all paediatric patients who had undergone transumbilical SPLV [Uni-X Single Port Access Laparoscopic System, Pnavel Systems, NJ, USA]. This novel 20-mm laparoscopic port has three working channels and gas insufflation access. The system also includes a variety of curved laparoscopic instruments that can be introduced through the SP. A Hassan technique through an incision within the inferior aspect of the umbilicus is used to obtain laparoscopic port access to the abdominal cavity. The SP is then fixed into position with pre-placed rectus facial sutures. Using a curved laparoscopic grasper and scissors, an incision is made within the posterior peritoneum on the medial and lateral aspects of the left testicular artery and veins, proximal to the vas deferens. The vessels, both artery and veins, are transected leaving clips both proximally and distally.

RESULTS

Transumbilical SPLV was completed in three consecutive adolescents (aged 13, 15 and 16 years) without placing any additional ports or conversion to open surgery. All procedures were performed for left-sided grade III varicoceles. The operative duration was <1 h for each procedure. All patients were discharged on the same day as their surgery and none required re-hospitalization. At a mean (range) follow-up of 8.7 (6-10) weeks there was a good cosmetic result, with no varicocele recurrence, or intraoperative or postoperative complications including wound infection, hydrocele, or incision site herniation.

CONCLUSION

We report the first use of a multicannula single laparoscopic port in children and for SPLV. This new laparoscopic approach, similar to any new technique, requires further experience to fully evaluate its benefits and limitations.

Adolescent varicocele: who is at risk?

OBJECTIVES

Varicocele results from the abnormal dilation of the veins of the pampiniform plexus and is the most common identifiable cause of male infertility. It can develop during puberty and thus affect the testicular growth and function. The aim of this study was to determine the prevalence and the risk factors for the development of the varicocele among Bulgarian boys.

METHODS

In a prospective study, 6200 boys from 5 regions of the country aged 0 to 19 years were evaluated for varicocele. All were clinically healthy. Height, weight, testicular volumes, penile length, and penile circumference were also examined.

RESULTS

Varicocele was found in 4.1% of all investigated boys, whereas in the age group 10 to 19 years, it was 7.9%. After adjustment for age, the negative factors associated with the development of the disorder were height, penile length, and penile circumference, whereas the weight and BMI had a protective role. The prevalence of varicocele demonstrated clear regional differences, and it was found significantly more often among dark-eyed boys. The incidence of the disease increased rapidly during midpuberty.

CONCLUSIONS

The incidence of varicocele is related to some somatometric parameters and with the accelerated pubertal development. Longitudinal studies are needed to clarify better the relations between the adolescent varicocele and puberty.

The treatment of adolescents presenting with a varicocele

In the last 10 years there have been many reports of children and adolescents with varicocele, but virtually none from the UK. There is an increasing incidence with age, to 19% by the age of 19 years. There is some evidence that a varicocele impairs the development of the affected testis; 9.3% of boys of 19 years old have a small testis as a result. Some aspects of testicular function are compromised. Treatment of the varicocele allows compensatory growth and testicular function. The surgical technique must be meticulous to avoid complications, particularly the formation of a hydrocele. Despite much research, the effect on fertility is unknown. The incidence of varicocele is much higher than that of male factor infertility. It is not known whether varicocele in adolescence impairs fertility or whether surgery restores fertility. At present the main indications for surgery are persistent delay in growth of >20%, bilateral varicocele and impaired spermatogenesis persisting beyond 18 years old.

Adolescent varicocele

PURPOSE OF REVIEW

Adolescent varicocele is a common lesion which remains poorly understood. Recent research in pathophysiology and surgical management has shed new light on this increasingly diagnosed clinical entity.

RECENT FINDINGS

Recent research demonstrates the potential importance of heat and oxidative stress patterns on testicular dysfunction with varicocele. The importance of testicular volume differentials as a surgical indication have been demonstrated. Surgical innovations have included artery sparing, often with microscopic magnification, and enhanced identification of lymphatics to reduce hydrocele with a laparoscopic approach.

SUMMARY

Optimal management of adolescent varicocele is being clarified. A conservative, selective approach based on testicular volume differentials and semen analysis findings seems appropriate. Techniques affording artery and lymphatic sparing should be employed.

Paternity after varicocelectomy: preoperative sonographic parameters of success

OBJECTIVE

This study was done to assess the sonographic findings that could predict the outcome of varicocele repair in the treatment of male infertility/subfertility related to varicocele.

METHODS

This was a retrospective study and follow-up of 107 selected patients with male factor infertility related to the presence of varicocele. The patients were classified into 2 groups according to their estimated testicular size by sonography. Group 1 included 80 patients with normal-sized testes (>15 cm(3)), and group 2 included 27 patients with small testes (10-15 cm(3)). The mean age +/- SD was 34 +/- 11 years. The mean duration of infertility was 3.4 +/- 1.4 years. They had oligospermia, asthenospermia, or oligoasthenospermia. The patients underwent low ligation varicocelectomy and were followed for 18 to 45 months after surgery for occurrence of paternity. Their scrotal sonographic findings were reviewed and correlated with the postoperative paternity rate.

RESULTS

Postoperative paternity was achieved in 24 patients (30%) of group 1 with normal-sized testes and in 3 patients (11%) of group 2 with small testes. In patients of group 1, the positive paternity rate was higher (36.6%) in patients with clinically detected varicocele, compared with only 16% of patients with subclinical varicocele. In addition, postoperative paternity was significantly higher in patients with bilateral varicocele (54.5%; P = .0099), patients with shunt-type varicocele (75%; P = .0117), and patients with a permanent grade of venous reflux (70%; P = .0148). No significant differences were noted between positive paternity rates in patients with mildly or markedly dilated veins.

CONCLUSIONS

The best preoperative sonographic parameters of success of varicocele repair are the presence of normal-sized testes, clinically palpable veins, bilateral varicocele, shunt-type varicocele, and a permanent grade of venous reflux. It does not matter how much the veins are dilated.